APPENDIX NINE (I) LETTER TO GUARDIAN FOR INFORMATION AND HISTORY [Vide Rule 48.6]- SS CODE

 

APPENDIX NINE (I)

LETTER TO GUARDIAN FOR INFORMATION AND 

HISTORY

[Vide Rule 48.6]

 

School________________

Place_________________

Date_________________

Dear Sir/Madam,

            The medical examination of (name of the pupil)____________________________ Std_____________________ Div__________________ is to be taken of _________________________

            Kindly fill up the information for the same as required below and send it with the pupil.

 

Signature of the head of the school.

 

1. Has the pupil suffered from any of the following diseases?

Please write the year in which he/she has so suffered –

 

(1) Smallpox    ____________________________________

 

(2) Measles ____________________________________

 

(3) Diptheria ____________________________________

 

(4) Complaints about tonsils and throat ____________________

 

(5) Diseases of the ear ____________________________________

 

(6) Diseases of the eye ____________________________________

 

(7) Rickets _____________________________________________

 

(8) Any other diseases (name it with date) _____________________

 

2. Was the pupil operated upon for anything? If so, please mention when the operation was made. A copy of the report of the operation, if available, should be produced.

 

3. Preventive measures against –

 

Smallpox – Vaccination when done:

Small pox – Revaccination (B.C.G.) if done, when:

Tripple other preventive measure:

Any other preventive measure:

 

4. Any ailments that the pupil usually suffers from:

 

Date:                                                                                                                                       Signature of the Guardian.